The
contents of our counseling, intake, or assessment forms and sessions are considered to be confidential. Both verbal information
and written records about a client cannot be shared with another party without the written consent of the client or the client’s
legal guardian. It is the policy of this clinic not to release any information about a client without a signed release of
information. Noted exceptions are as follows:

Duty to Warn and Protect

When a client discloses intentions or a plan to
harm another person, the health care professional is required to warn the intended victim and report this information to legal
authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required
to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing
a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in
danger of abuse, the health care professional is required to report this information to the appropriate social service and/or
legal authorities.

Prenatal Exposure to Controlled Substances

Health
care professionals may be required to report admitted prenatal exposure to controlled substances that are potentially harmful
if the life of the unborn child is placed at risk. In the Event of a Client’s Death In the event of a client’s
death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records.

Professional Misconduct

Professional misconduct by a health care
professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting
is being held regarding the health care professional’s actions, related records may be released in order to substantiate
disciplinary concerns.

Court Orders

Health care professionals are required
to release records of clients when a court order has been placed. It is our policy to inform you of the Court Order or Subpoena
and or our intent to release your records prior to releasing them to any party.

Minors/Guardianship

Parents or legal guardians of non-emancipated minor clients have the right to access the client’s
records.

Other Provisions

When fees for services are not paid in
a timely manner, various methods may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis,
treatment plan, case notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and
the client’s credit report may state the amount owed, time frame, and the name of the clinic.

Insurance companies and other third-party payers are
given information that they request regarding services to clients. Information which may be requested includes type of services,
dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.
This information is only given upon written request and to supply them with information needed to process claims and to approve
further or additional treatment services. If you request, we will notify you prior to the release of any of your information.
Please note that certain demographic and diagnosis information is released to permit your insurance company to pay for the
services that I have rendered. Information about clients may be disclosed in consultations with other professionals in order
to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed.
Clinical information about the client is discussed when you are referred or when you request that information be sent to another
provider. When couples, groups, or families are receiving services, a joint file is kept for individuals for information disclosed
that is of a confidential nature. The information includes (a) testing results, (b) information given to the mental health
professional not in the presence of other person(s) utilizing services, (c) information received from other sources about
the client, (d) diagnosis, (e) treatment plan, (f) individual reports/summaries, and (h) information that has been requested
to be separate. The material disclosed in conjoint family or couples sessions, in which each party discloses such information
in each other’s presence, is kept in the client of records file in the form of case notes and clinical data. In the
event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations
or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please tell us where we
may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone
you at home or work, we do not say the name of the clinic or the nature of the call, but rather the mental health professional’s
first name only. If this information is not provided to us during the intake process, we will adhere to the following procedure
when making phone calls: First we will ask to speak to the client (or guardian) without identifying the name of the clinic.
If the person answering the phone asks for more identifying information we will say that it is a personal call. We will not
identify the clinic (to protect confidentiality). If we reach an answering machine or voice mail we will follow the same guidelines.

I also understand that all electronic transmission of data is covered
by these policies and procedures. I understand that all efforts will be taken by Steven C. Holeman, PhD and Living Solutions,
LLC to maintain my information in a confidential manner and that I can inquire at any time about the confidentiality of my
information and clinical record.

I
agree to the above limits of confidentiality and understand their meanings and ramifications and agree to these policies during
the time that I am in treatment with Steven C. Holeman, PhD and Living Solutions, LLC.

As a patient of the Steven
C. Holeman, PhD and Living Solutions, LLC, you are entitled to the rights outlined in the Mental Health and Developmental
Disabilities Confidentiality Act and Chapter 2 of the Mental Health and Developmental Disabilities Code. These rights include,
but are not limited to, the following:

You have the right to be provided with adequate and
humane care and services in the least restrictive environment.

You have the right to be free from abuse and neglect.

You have the
right to have services provided to you following the development of an individualized treatment plan.

You have the right to have your
treatment plan reviewed periodically, but at least once every six months.

You have the right to participate in the development
and review of your treatment plan, when appropriate.

You have the right to be notified in writing of the side-effects of
medication if your service includes the administration of psychotropic medication(s).

You have the right to refuse services, including
medication, and to be informed of any consequences related to service delivery should you refuse medication.

You have the
right to be free from physical restraint/seclusion, unless such restraint/seclusion is being used as a therapeutic measure
to prevent you from causing physical harm to yourself or others.

You have the right to contact MO Center for Disability
Law or any other agency to advocate on your behalf. You have the right to be offered staff assistance in contacting these
organizations including being given the addresses and phone numbers.

You have the right to present grievances or to
appeal adverse decisions related to your services. You have the right to make such grievances or appeals to the highest level
possible in the agency.

You are entitled to have your rights explained to you using a language or method of communication
you understand upon commencement of services.

You have the right not to have services denied, suspended, reduced or terminated
for exercising your rights.

You have the right not to be denied mental health services because of age, sex, race, religious
belief, ethnic origin, marital status, physical or mental disability, or criminal record that is unrelated to present dangerousness.

Your Records
are protected under the Federal Confidentiality Regulation and cannot be disclosed without your consent.

HIPAA Notice of Information
and Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Health Record Information

I understand
the necessity of maintaining and assuring your medical information remains private and confidential at all times.I have always been committed to safeguarding your privacy.I want you to understand how I protect
the personal and medical information you share with me.

Upon registration as a client you will be asked to sign a consent form allowing me to
bill and receive payment from your insurance company sharing only necessary information for that purpose.This
consent also permits me to share information with other medical facilities including specialists, laboratories, and other
licensed providers, as required in the course of treatment necessary for providing you with the best care.

Each
time you visit a hospital, a physician, or another health care provider, the provider makes a record of your visit.
Typically, this record contains your health history, current symptoms, examination and test results, diagnoses, treatment,
and plan for future care or treatment. This information, often referred to as your medical record, serves as the following:

vBasis for planning your care and treatment.

vMeans of communication among
the many health professionals who contribute to your care.

vLegal document describing
the care that you received.

vMeans by which you or a third-party payer can verify that you actually
received the services billed for.

vTool in medical or psychological education.

vSource
of information for public health officials charged with improving the health of the regions they serve.

vTool
to assess the appropriateness and quality of care that you received.

vTool to improve the quality
of health care and achieve better patient outcomes.

Understanding what
is in your records and how your health information is used helps you to--

Your Rights under the Federal Privacy Standard

Although
your health records are the physical property of the health care provider who completed it, you have the following rights
with regard to the information contained therein:

vRequest restriction on uses and disclosures of your health information
for treatment, payment, and health care operations. “Health care operations” consist of activities that
are necessary to carry out the operations of the provider, such as quality assurance and peer review. The right to request
restriction does not extend to uses or disclosures permitted or required under the following sections of the federal privacy
regulations: § 164.502(a)(2)(i) (disclosures to you), or 164.512 (uses and disclosures not requiring a consent
or an authorization). The latter uses and disclosures include, for example, those required by law, such as mandatory
communicable disease reporting. In those cases, you do not have a right to request restriction. The consent to
use and disclose your individually identifiable health information provides the ability to request restriction. We do
not, however, have to agree to the restriction. If we do, we will adhere to it unless you request otherwise or we give
you advance notice. You may also ask us to communicate with you by alternate means, and if the method of communication is
reasonable, we must grant the alternate communication request. You may request restriction or alternate communications
on the consent form for treatment, payment, and health care operations.

vObtain a copy of this notice of information practices.

vInspect and copy your health
information upon request. Again, this right is not absolute. In certain situations, such as if access would cause
harm, we can deny access. You do not have a right of access to the following:

²Psychotherapy notes. Such
notes consist of those notes that are recorded in any medium by a health care provider who is a mental health professional
documenting or analyzing a conversation during a private, group, joint, or family counseling session and that are separated
from the rest of your medical record.

²Information compiled in reasonable
anticipation of or for use in civil, criminal, or administrative actions or proceedings.

²Protected health information
(“PHI”) that is subject to the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”), 42 U.S.C.
§ 263a, to the extent that giving you access would be prohibited by law.

²Information that was obtained from someone other than a health care provider
under a promise of confidentiality and the requested access would be reasonably likely to reveal the source of the information.

In other situations, I may deny you access, but if I do, I must provide you the reason for denying access. These
reasons may include the following:

vA licensed healthcare professional, such as your attending physician or
counselor, has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the
life or physical safety of yourself or another person.

vPHI makes reference to another person (other than a health care provider)
and a licensed health care provider has determined, in the exercise of professional judgment, that the access is reasonably
likely to cause substantial harm to such other person.

vThe request is made by your personal representative and a licensed health
care professional has determined, in the exercise of professional judgment, that giving access to such personal representative
is reasonably likely to cause substantial harm to you or another person.

If I grant access, I will tell you what, if anything, you have to do to get access. I reserve the right to charge
a reasonable, cost-based fee for making copies.

vRequest amendment/correction of your health information. I do not
have to grant the request if the following conditions exist:

vI did not create the record. If, as in the case of a consultation report from another provider,
we did not create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek amendment/correction
from the party creating the record. If the party amends or corrects the record, we will put the corrected record into
our records.

vThe records
are not available to you as discussed immediately above.

vThe record is accurate and complete.

If I deny your request for amendment/correction, I will notify you why, how you can
attach a statement of disagreement to your records (which we may rebut), and how you can complain. If I grant the request,
I will make the correction and distribute the correction to those who need it and those whom you identify to me that you want
to receive the corrected information.

vObtain an accounting of non-routine uses and disclosures, those other than for treatment, payment,
and health care operations. We do not need to provide an accounting for the following disclosures:

vTo you for disclosures of protected health information to you.

vTo persons involved in your care and persons acting on your behalf.

vFor national
security or intelligence purposes.

vTo correctional institutions or law enforcement officials.

vThat occurred before April 14, 2003.

I must provide the accounting
within 60 days. The accounting must include the following information:

vDate of each non-routine disclosure.

vName and address of the organization or person who received the protected
health information.

vBrief
description of the information disclosed.

vBrief statement of the purpose of the disclosure that reasonably informs you of the basis for the
disclosure or, in lieu of such statement, a copy of your written authorization or a copy of the written request for disclosure.

I
reserve the right to charge a reasonable, cost-based fee.

Our Responsibilities under the Federal Privacy Standard

In addition to
providing you your rights, as detailed above, the federal privacy standard requires me to take the following measures:

vMaintain
the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical
safeguards to protect the information.

vProvide you this notice as to our legal duties and privacy practices with respect to individually
identifiable health information that we collect and maintain about you.

vAbide by the terms of this notice.

vTrain our personnel concerning privacy and confidentiality.

vImplement a sanction policy to discipline those who breach privacy/ confidentiality
or our policies with regard thereto.

vMitigate (lessen the harm of) any breach of privacy/confidentiality.

We will not use or disclose
your health information without your consent or authorization, except as described in this notice or otherwise required.

How to Get More Information or to Report a Problem

If you have
questions, would like to report a problem, and/or would like additional information, you may contact me at (816) 739-0876.
The effective date of this Notice is April 1, 2003.

I RESERVE THE RIGHT TO CHANGE MY PRACTICES
AND TO MAKE THE NEW PROVISIONS EFFECTIVE FOR ALL INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION THAT I MAINTAIN. IF I
CHANGE OUR INFORMATION PRACTICES, I WILL MAIL A REVISED NOTICE TO THE ADDRESS THAT YOU HAVE GIVEN ME.